Hybrid minimally invasive esophagectomy of a large, obstructive esophageal hemangioma: a case report

The human esophagus is a muscular tube that serves as the essential passageway for food, moving it from the throat to the stomach. Occasionally, this tube develops growths, some of which are benign, meaning they are not cancerous. Among the rarest of these benign growths are hemangiomas, which are essentially tangles of blood vessels that form within the wall of the esophagus. Because these tumors are made of blood vessels, they are prone to bleeding, a characteristic that makes them difficult to handle. While many of these growths are small and cause no trouble, a few become large enough to block the passage of food or grow deep into the tissue layers of the organ. When a tumor is this large and vascular, standard medical tools used to examine the inside of the body can be dangerous to use, as the act of taking a sample or attempting to remove it might trigger severe hemorrhage. This leaves doctors with a difficult choice: how to remove a dangerous, bleeding-prone mass without causing the patient to bleed out during the procedure.

A team of surgeons at the University of Pittsburgh Medical Center recently documented the successful removal of such a challenging tumor in a sixty-five-year-old man. The patient had suffered from worsening difficulty swallowing and weight loss for six years due to a massive growth inside his esophagus. He had previously undergone an attempt at surgery at another hospital, where the doctors opened his chest to remove the mass but were forced to stop because the tumor was so filled with blood vessels that it posed an immediate risk of uncontrollable bleeding. When the patient arrived at Pittsburgh, imaging revealed a sixteen-centimeter mass that had narrowed the esophageal tube but had not broken through the inner lining. Because the risk of bleeding was so high, the medical team decided against taking a tissue sample before surgery, relying instead on the imaging and the patient's history to guide their plan.

The surgical team chose a hybrid approach, a method that combines the safety of open surgery with the recovery benefits of minimally invasive techniques. They began by exploring the chest cavity using a camera and small instruments, but they quickly encountered dense scar tissue from the patient's previous operation. Recognizing that the complex adhesions and the tumor's extreme vascularity required more direct control, the surgeons converted the procedure to a traditional open incision through the patient's old surgical scar. This allowed them to carefully separate the tumor from the surrounding structures, including the heart and major blood vessels, without causing a rupture. Once the tumor was safely freed, the team switched to a minimally invasive approach for the reconstruction phase. They used small incisions in the abdomen to create a new pathway for food using a section of the stomach, a procedure known as creating a gastric conduit. They also performed a pyloroplasty, a minor adjustment to the valve between the stomach and the small intestine to help food move through more easily, and placed a feeding tube to support the patient's nutrition during recovery.

The removed tumor measured ten centimeters in its largest dimension and was found to involve the deep layers of the esophageal wall. Pathological examination confirmed that the growth was indeed a hemangioma, composed of blood vessel cells, and that the surgeons had successfully removed it entirely with clear margins, leaving no cancerous or abnormal cells behind. The patient experienced a minor complication where a small amount of fluid leaked from the connection point between the stomach and the remaining esophagus, but this was managed without further surgery by adjusting the drainage tubes and allowing the area to heal. He was able to drink clear liquids and leave the hospital twelve days after the operation. At long-term follow-up, the patient reported only mild difficulty swallowing and heartburn, with no sign that the tumor had returned.

This case demonstrates that for large, deeply embedded, and highly vascular tumors that cannot be safely removed through the mouth or by simple shelling out, a hybrid surgical strategy offers a viable solution. By using an open approach in the chest to secure the blood supply and remove the mass, and then using minimally invasive techniques to rebuild the digestive tract, surgeons can achieve a complete removal while minimizing the trauma to the patient's body. The successful outcome in this patient suggests that this combined method is a reasonable and definitive way to treat these rare and complex esophageal growths when less invasive options are not possible.